Cumberland_Well Abandonment_20230915 (18)

WELL ABANDONMENT RECORD For Internal Use ONLY: l
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror 7a.Number of wells being abandoned. 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple. injection or non-wafer supply ivells ONLY ivith the same
constructiordabandonnient,you can subneil'one form.
4308-A
NC Well Contractor Certification Number
7b.Approximate volume of wale!remaining in well(s): 280 (gal.)
Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#: 1
List all applicable well construction permits(i.e.County,State,Variance,etc.)tfknown ]d.Amount of disinfectant used 1 lbs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout i ❑Drill Cuttings
DIrri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑GroundwaterRemediation 500 ibs bentonite slurry
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer pulled pump from well
❑Geothermal(Heating/CoolingReturn) ❑Other(MlSYirurlder*lg)-.1 ,{---
1 D V iLmeasured depth of well and SWL
4.Date well(s)abandoned: 5-18-22 Disinfected well
r
SEP 1 •. 2023
5a.Well location: u
t r r m ed full of bentonite slur
ln,a .'^��.,k. �� p slurry
TA Loving Company
ptr,vs�,.
Facility/Owner Name Facility ID#(if applicable)
8.Certification:
2101 Pinewood Terrace, Fayetteville, NC 28304 5-18-22
Physical Address,City,and Zip Sigrtad&e of Certified Well Contractor or Well Owner Date
Cumberland
By signing this form, /hereby certify that the well(s)ivas(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 9.Site diagram or additional well details:
35.025903 -79.022596 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construciion/abandonnient,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.We11IDt1:
abandonment to the following:
'
Division of Water Quality,Information Processing Unit,
6b.Total well depth. 340 (fL) 1617 Mail Service C i enter,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (In.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface: 150 ({G) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fL) 10c.For Water Supply&Iniect Ion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
6E Inner casing/tubing length(if known): 241 (ft.) 1
I '
6g.Screen length(if known): 00
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013
I

E
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror I ! 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply tivells ONLY ivith the same
construction/abandonment,you can subnttt one form.
4308-A
NC Well Contractor Certification Number 7b.Approximate volume of watery remaining in well(s): 12 (gal.)
Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits fl.e.County,State,Variance,etc.)lfknown 7d.Amount of disinfectant used: 1 lbS
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout i ❑Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
Dlrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected abo'v%.provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 300 Ibs bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stotmwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer pulled pump from well,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
,,, r- ;• 4 Measured depth of well and SWL
5-18-22 �
4.Date well(s)abandoned: p Disinfected well
1
5a.Well location: SEP 5 2023 filled with bentonite chips
TA Loving Company Irh rnacmil��_� , �j
Facility/Owner Name FaciW''%.tBhpp1g=ble) S•Certification:
2107 Pinewood Terrace, Fayetteville, NC 28304 ,�(� 5-18-22
Physical Address,City,and Zip Signatfife of Certified Well Contractor of Well Owner Date
Cumberland
By signing this form, 1 hereby certify that the rve!l(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standatds
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well!details:
35.024281 -79.022215 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY ivid;the same construction/abandonment,you can submit one fornn• 10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID#:
abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 52 (n•) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: I
6d.Water level below ground surface 34 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniectwn Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6E Inner casing/tubing length(if known): (ft.) where abandoned.
I
6g.Screen length(if known): (fL)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
I ;

1
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror ' i 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple infection or non-water supply ivells ONLY tivith rile same
4308-A constructiowabandonmeni,you can submit one form.
NC Well Contractor Certification Number
7b.Approximate volume of wati (r remaining in well(s): 51 (gal.)
Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit il:
List all applicable ivell construction permits(i.e.County,State,Variance,etc.)fit known 7d.Amount of disinfectant used: 1 Ibs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout R3 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
OIrrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 850 Ibs bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer pulled pump from well
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
1. ,�-�,t +; �-•�; Measured depth of well and SWL
4.Date well(s)abandoned: 5-18-22 �..��"�t a' Disinfected well
5a.Well location: SEP 1 5 2023 filled with bentonite chips
TA Loving Company
lRSvf7��...,rt fir,�r.,n..'�:ir�L,42a�
Facility/Owner Name FacqWjiV,tfflajlacable) S.Certification:
2103 Pinewood Terrace, Fayetteville, NC 283047z 5-18-22
Physical Address,City,and Zip Signa a of Certified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constriction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 9.Site diagram or additional well details:
35.025848 -79.022571 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMTTTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the saute constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following: j
6a.Well ID#:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 65 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
30 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (111) 1636 Mail Service Center,Raleigh,NC 27699-1636
1
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Infection;Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6E Inner casing/tubing length(if known): (ft.) where abandoned.
I
6g.Screen length(if known): (tt.)
I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
7
i

l
I �
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror f ! 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-r eater supply u•e/!s ONLY with the same
construction/abandonment,you can submit,one form.
4 4308-A � � 286
Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): (gal.)
Bills Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable ivell construction permits(i.e.County,State,Variance,etc.)iflarown 7d.Amount of disinfectant used: 2 lbs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
Elh-ri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1150 lbs bentonite slurry
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer pulled pump from well
❑Geothermal(Heating/Cooling Return) ❑Oth e:iplpirt unr(ex:7g�i "'f
r �- -- -- Measured depth of well and SWL
4.Date well(s)abandoned: 5-18-22 S-E P 1 5 2023 Disinfected well
,5a.Well location: lttfi.`,r o;cn U" pumped full of bentonite slurry
TA Loving Company pN111lar11:s
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
2103 Pinewood Terrace, Fayetteville, NC 28304 D� 5-18-22
Physical Address,City,and Zip Signatiffe ofCertified Well Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
35.025832 -79.022606 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS:
Attach well construction record(s)if available. For multiple injection or non-water supply
ivells ONLYwith thesame constnrctionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well HMI:
abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
340 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
�
10b.For Infection Wells: In addition to sending the form to the address in 10a
6 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
I
145 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface. (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (f0 the address(es) above, also submit one copy of this forth within 30 days of
completion of well abandonment to the county health department of the county
6E Inner casing/tubing length(if known): 348 (ft) where abandoned.
i
i
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Qi ualty Revised March 2013
I
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